|
EP Catheter-Diagnostic
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1730
|
| Hospital Charge Code |
4139317
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
EP Comprehensive Study w/Induction
|
Facility
|
OP
|
$18,016.00
|
|
|
Service Code
|
CPT 93620
|
| Hospital Charge Code |
3052508
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$7,381.60 |
| Max. Negotiated Rate |
$29,526.40 |
| Rate for Payer: Aetna Commercial |
$16,214.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,493.76
|
| Rate for Payer: Aetna Managed Medicare |
$7,381.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,548.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,381.60
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cigna Commercial |
$16,574.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,381.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,081.75
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,381.60
|
| Rate for Payer: Health EOS Commercial |
$16,034.24
|
| Rate for Payer: HFN Commercial |
$16,574.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,459.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,381.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,381.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,381.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,381.60
|
| Rate for Payer: Multiplan Commercial |
$14,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,072.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,574.72
|
| Rate for Payer: Quartz Beloit One Network |
$8,827.84
|
| Rate for Payer: Quartz Commercial |
$11,710.40
|
| Rate for Payer: Quartz Medicare Advantage |
$7,381.60
|
| Rate for Payer: The Alliance Commercial |
$29,526.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,381.60
|
| Rate for Payer: WEA Trust Commercial |
$9,908.80
|
| Rate for Payer: Wellcare Medicare |
$7,381.60
|
| Rate for Payer: WPS Commercial |
$13,344.45
|
|
|
EP Comprehensive Study w/Induction
|
Facility
|
IP
|
$18,016.00
|
|
|
Service Code
|
CPT 93620
|
| Hospital Charge Code |
3052508
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$8,827.84 |
| Max. Negotiated Rate |
$16,574.72 |
| Rate for Payer: Aetna Commercial |
$16,214.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,493.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,548.48
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cigna Commercial |
$16,574.72
|
| Rate for Payer: Health EOS Commercial |
$16,034.24
|
| Rate for Payer: HFN Commercial |
$16,574.72
|
| Rate for Payer: Multiplan Commercial |
$14,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,809.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,574.72
|
| Rate for Payer: Quartz Beloit One Network |
$8,827.84
|
| Rate for Payer: Quartz Commercial |
$10,809.60
|
| Rate for Payer: WEA Trust Commercial |
$9,908.80
|
| Rate for Payer: WPS Commercial |
$13,344.45
|
|
|
EP Comprehensive Study w/o Induction
|
Facility
|
OP
|
$18,016.00
|
|
|
Service Code
|
CPT 93619
|
| Hospital Charge Code |
3052507
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$7,381.60 |
| Max. Negotiated Rate |
$29,526.40 |
| Rate for Payer: Aetna Commercial |
$16,214.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,493.76
|
| Rate for Payer: Aetna Managed Medicare |
$7,381.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,548.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,381.60
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cigna Commercial |
$16,574.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,381.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,081.75
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,381.60
|
| Rate for Payer: Health EOS Commercial |
$16,034.24
|
| Rate for Payer: HFN Commercial |
$16,574.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,459.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,381.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,381.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,381.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,381.60
|
| Rate for Payer: Multiplan Commercial |
$14,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,072.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,574.72
|
| Rate for Payer: Quartz Beloit One Network |
$8,827.84
|
| Rate for Payer: Quartz Commercial |
$11,710.40
|
| Rate for Payer: Quartz Medicare Advantage |
$7,381.60
|
| Rate for Payer: The Alliance Commercial |
$29,526.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,381.60
|
| Rate for Payer: WEA Trust Commercial |
$9,908.80
|
| Rate for Payer: Wellcare Medicare |
$7,381.60
|
| Rate for Payer: WPS Commercial |
$13,344.45
|
|
|
EP Comprehensive Study w/o Induction
|
Facility
|
IP
|
$18,016.00
|
|
|
Service Code
|
CPT 93619
|
| Hospital Charge Code |
3052507
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$8,827.84 |
| Max. Negotiated Rate |
$16,574.72 |
| Rate for Payer: Aetna Commercial |
$16,214.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,493.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,548.48
|
| Rate for Payer: Cash Price |
$5,404.80
|
| Rate for Payer: Cigna Commercial |
$16,574.72
|
| Rate for Payer: Health EOS Commercial |
$16,034.24
|
| Rate for Payer: HFN Commercial |
$16,574.72
|
| Rate for Payer: Multiplan Commercial |
$14,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,809.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,574.72
|
| Rate for Payer: Quartz Beloit One Network |
$8,827.84
|
| Rate for Payer: Quartz Commercial |
$10,809.60
|
| Rate for Payer: WEA Trust Commercial |
$9,908.80
|
| Rate for Payer: WPS Commercial |
$13,344.45
|
|
|
EP Eval Cardiovert-Defibrilato
|
Facility
|
IP
|
$542.00
|
|
| Hospital Charge Code |
3052574
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$265.58 |
| Max. Negotiated Rate |
$498.64 |
| Rate for Payer: Aetna Commercial |
$487.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$287.26
|
| Rate for Payer: Cash Price |
$162.60
|
| Rate for Payer: Cigna Commercial |
$498.64
|
| Rate for Payer: Health EOS Commercial |
$482.38
|
| Rate for Payer: HFN Commercial |
$498.64
|
| Rate for Payer: Multiplan Commercial |
$433.60
|
| Rate for Payer: NAPHCARE Commercial |
$325.20
|
| Rate for Payer: Preferred Network Access Commercial |
$498.64
|
| Rate for Payer: Quartz Beloit One Network |
$265.58
|
| Rate for Payer: Quartz Commercial |
$325.20
|
| Rate for Payer: WEA Trust Commercial |
$298.10
|
| Rate for Payer: WPS Commercial |
$401.46
|
|
|
EP Eval Cardiovert-Defibrilato
|
Facility
|
OP
|
$542.00
|
|
| Hospital Charge Code |
3052574
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$151.76 |
| Max. Negotiated Rate |
$2,168.00 |
| Rate for Payer: Aetna Commercial |
$487.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.12
|
| Rate for Payer: Aetna Managed Medicare |
$151.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$352.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$271.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$260.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$287.26
|
| Rate for Payer: Cash Price |
$162.60
|
| Rate for Payer: Cigna Commercial |
$498.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$303.30
|
| Rate for Payer: Health EOS Commercial |
$482.38
|
| Rate for Payer: HFN Commercial |
$498.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$406.50
|
| Rate for Payer: Multiplan Commercial |
$433.60
|
| Rate for Payer: NAPHCARE Commercial |
$325.20
|
| Rate for Payer: Preferred Network Access Commercial |
$498.64
|
| Rate for Payer: Quartz Beloit One Network |
$265.58
|
| Rate for Payer: Quartz Commercial |
$352.30
|
| Rate for Payer: Quartz Medicare Advantage |
$325.20
|
| Rate for Payer: The Alliance Commercial |
$2,168.00
|
| Rate for Payer: United Healthcare PPO |
$406.50
|
| Rate for Payer: WEA Trust Commercial |
$298.10
|
| Rate for Payer: WPS Commercial |
$401.46
|
|
|
EP F/U Pace/Record Post Therapy
|
Facility
|
OP
|
$2,215.00
|
|
|
Service Code
|
CPT 93624
|
| Hospital Charge Code |
3052511
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,063.20 |
| Max. Negotiated Rate |
$29,526.40 |
| Rate for Payer: Aetna Commercial |
$1,993.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,904.90
|
| Rate for Payer: Aetna Managed Medicare |
$7,381.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,439.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,107.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,063.20
|
| Rate for Payer: Anthem Medicare Advantage |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,173.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,381.60
|
| Rate for Payer: Cash Price |
$664.50
|
| Rate for Payer: Cash Price |
$664.50
|
| Rate for Payer: Cigna Commercial |
$2,037.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,381.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,239.51
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,381.60
|
| Rate for Payer: Health EOS Commercial |
$1,971.35
|
| Rate for Payer: HFN Commercial |
$2,037.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,459.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,381.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,381.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,381.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,381.60
|
| Rate for Payer: Multiplan Commercial |
$1,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,072.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,037.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,085.35
|
| Rate for Payer: Quartz Commercial |
$1,439.75
|
| Rate for Payer: Quartz Medicare Advantage |
$7,381.60
|
| Rate for Payer: The Alliance Commercial |
$29,526.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,381.60
|
| Rate for Payer: WEA Trust Commercial |
$1,218.25
|
| Rate for Payer: Wellcare Medicare |
$7,381.60
|
| Rate for Payer: WPS Commercial |
$1,640.65
|
|
|
EP F/U Pace/Record Post Therapy
|
Facility
|
IP
|
$2,215.00
|
|
|
Service Code
|
CPT 93624
|
| Hospital Charge Code |
3052511
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,085.35 |
| Max. Negotiated Rate |
$2,037.80 |
| Rate for Payer: Aetna Commercial |
$1,993.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,904.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,173.95
|
| Rate for Payer: Cash Price |
$664.50
|
| Rate for Payer: Cigna Commercial |
$2,037.80
|
| Rate for Payer: Health EOS Commercial |
$1,971.35
|
| Rate for Payer: HFN Commercial |
$2,037.80
|
| Rate for Payer: Multiplan Commercial |
$1,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,329.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,037.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,085.35
|
| Rate for Payer: Quartz Commercial |
$1,329.00
|
| Rate for Payer: WEA Trust Commercial |
$1,218.25
|
| Rate for Payer: WPS Commercial |
$1,640.65
|
|
|
EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN 93641
|
Professional
|
Both
|
$3,427.00
|
|
|
Service Code
|
CPT 93641
|
| Hospital Charge Code |
5551964
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$582.54 |
| Max. Negotiated Rate |
$3,255.65 |
| Rate for Payer: Aetna Commercial |
$3,255.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,947.22
|
| Rate for Payer: Cash Price |
$1,028.10
|
| Rate for Payer: Cash Price |
$1,028.10
|
| Rate for Payer: Cigna Commercial |
$3,255.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$582.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,056.20
|
| Rate for Payer: Health EOS Commercial |
$3,118.57
|
| Rate for Payer: HFN Commercial |
$3,255.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,038.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,038.05
|
| Rate for Payer: Multiplan Commercial |
$2,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,255.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,507.88
|
| Rate for Payer: Quartz Commercial |
$1,953.39
|
| Rate for Payer: The Alliance Commercial |
$1,713.50
|
| Rate for Payer: United Healthcare Medicaid |
$582.54
|
| Rate for Payer: WEA Trust Commercial |
$1,884.85
|
| Rate for Payer: WPS Commercial |
$2,538.38
|
|
|
EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN 9364126
|
Professional
|
Both
|
$3,427.00
|
|
|
Service Code
|
CPT 93641 26
|
| Hospital Charge Code |
5551965
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,011.24 |
| Max. Negotiated Rate |
$3,255.65 |
| Rate for Payer: Aetna Commercial |
$3,255.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,947.22
|
| Rate for Payer: Cash Price |
$1,028.10
|
| Rate for Payer: Cash Price |
$1,028.10
|
| Rate for Payer: Cigna Commercial |
$3,255.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,713.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,056.20
|
| Rate for Payer: Health EOS Commercial |
$3,118.57
|
| Rate for Payer: HFN Commercial |
$3,255.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,011.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,011.24
|
| Rate for Payer: Multiplan Commercial |
$2,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,255.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,507.88
|
| Rate for Payer: Quartz Commercial |
$1,953.39
|
| Rate for Payer: The Alliance Commercial |
$1,713.50
|
| Rate for Payer: WEA Trust Commercial |
$1,884.85
|
| Rate for Payer: WPS Commercial |
$2,538.38
|
|
|
EP ICD Threshold Eval@Ins/Rep
|
Facility
|
OP
|
$8,040.00
|
|
|
Service Code
|
CPT 93640
|
| Hospital Charge Code |
3052512
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,251.20 |
| Max. Negotiated Rate |
$32,160.00 |
| Rate for Payer: Aetna Commercial |
$7,236.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,914.40
|
| Rate for Payer: Aetna Managed Medicare |
$2,251.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,226.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,020.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,859.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,261.20
|
| Rate for Payer: Cash Price |
$2,412.00
|
| Rate for Payer: Cigna Commercial |
$7,396.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,499.18
|
| Rate for Payer: Health EOS Commercial |
$7,155.60
|
| Rate for Payer: HFN Commercial |
$7,396.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,030.00
|
| Rate for Payer: Multiplan Commercial |
$6,432.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,824.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,396.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,939.60
|
| Rate for Payer: Quartz Commercial |
$5,226.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,824.00
|
| Rate for Payer: The Alliance Commercial |
$32,160.00
|
| Rate for Payer: WEA Trust Commercial |
$4,422.00
|
| Rate for Payer: WPS Commercial |
$5,955.23
|
|
|
EP ICD Threshold Eval@Ins/Rep
|
Facility
|
IP
|
$8,040.00
|
|
|
Service Code
|
CPT 93640
|
| Hospital Charge Code |
3052512
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,939.60 |
| Max. Negotiated Rate |
$7,396.80 |
| Rate for Payer: Aetna Commercial |
$7,236.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,914.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,261.20
|
| Rate for Payer: Cash Price |
$2,412.00
|
| Rate for Payer: Cigna Commercial |
$7,396.80
|
| Rate for Payer: Health EOS Commercial |
$7,155.60
|
| Rate for Payer: HFN Commercial |
$7,396.80
|
| Rate for Payer: Multiplan Commercial |
$6,432.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,824.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,396.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,939.60
|
| Rate for Payer: Quartz Commercial |
$4,824.00
|
| Rate for Payer: WEA Trust Commercial |
$4,422.00
|
| Rate for Payer: WPS Commercial |
$5,955.23
|
|
|
EP ICD Threshold Eval Post Implant
|
Facility
|
OP
|
$8,131.00
|
|
|
Service Code
|
CPT 93641
|
| Hospital Charge Code |
3052513
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,276.68 |
| Max. Negotiated Rate |
$32,524.00 |
| Rate for Payer: Aetna Commercial |
$7,317.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,992.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,276.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,285.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,065.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,902.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,309.43
|
| Rate for Payer: Cash Price |
$2,439.30
|
| Rate for Payer: Cigna Commercial |
$7,480.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,550.11
|
| Rate for Payer: Health EOS Commercial |
$7,236.59
|
| Rate for Payer: HFN Commercial |
$7,480.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,098.25
|
| Rate for Payer: Multiplan Commercial |
$6,504.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,878.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,480.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,984.19
|
| Rate for Payer: Quartz Commercial |
$5,285.15
|
| Rate for Payer: Quartz Medicare Advantage |
$4,878.60
|
| Rate for Payer: The Alliance Commercial |
$32,524.00
|
| Rate for Payer: WEA Trust Commercial |
$4,472.05
|
| Rate for Payer: WPS Commercial |
$6,022.63
|
|
|
EP ICD Threshold Eval Post Implant
|
Facility
|
IP
|
$8,131.00
|
|
|
Service Code
|
CPT 93641
|
| Hospital Charge Code |
3052513
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,984.19 |
| Max. Negotiated Rate |
$7,480.52 |
| Rate for Payer: Aetna Commercial |
$7,317.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,992.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,309.43
|
| Rate for Payer: Cash Price |
$2,439.30
|
| Rate for Payer: Cigna Commercial |
$7,480.52
|
| Rate for Payer: Health EOS Commercial |
$7,236.59
|
| Rate for Payer: HFN Commercial |
$7,480.52
|
| Rate for Payer: Multiplan Commercial |
$6,504.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,878.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,480.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,984.19
|
| Rate for Payer: Quartz Commercial |
$4,878.60
|
| Rate for Payer: WEA Trust Commercial |
$4,472.05
|
| Rate for Payer: WPS Commercial |
$6,022.63
|
|
|
EP ICD Threshold Eval W/Reprogram
|
Facility
|
IP
|
$8,340.00
|
|
|
Service Code
|
CPT 93642
|
| Hospital Charge Code |
3052514
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,086.60 |
| Max. Negotiated Rate |
$7,672.80 |
| Rate for Payer: Aetna Commercial |
$7,506.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,172.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,420.20
|
| Rate for Payer: Cash Price |
$2,502.00
|
| Rate for Payer: Cigna Commercial |
$7,672.80
|
| Rate for Payer: Health EOS Commercial |
$7,422.60
|
| Rate for Payer: HFN Commercial |
$7,672.80
|
| Rate for Payer: Multiplan Commercial |
$6,672.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,004.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,672.80
|
| Rate for Payer: Quartz Beloit One Network |
$4,086.60
|
| Rate for Payer: Quartz Commercial |
$5,004.00
|
| Rate for Payer: WEA Trust Commercial |
$4,587.00
|
| Rate for Payer: WPS Commercial |
$6,177.44
|
|
|
EP ICD Threshold Eval W/Reprogram
|
Facility
|
OP
|
$8,340.00
|
|
|
Service Code
|
CPT 93642
|
| Hospital Charge Code |
3052514
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,176.34 |
| Max. Negotiated Rate |
$7,672.80 |
| Rate for Payer: Aetna Commercial |
$7,506.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,172.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,176.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,421.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,170.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,003.20
|
| Rate for Payer: Anthem Medicare Advantage |
$1,176.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,420.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,176.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,176.34
|
| Rate for Payer: Cash Price |
$2,502.00
|
| Rate for Payer: Cash Price |
$2,502.00
|
| Rate for Payer: Cigna Commercial |
$7,672.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,176.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,667.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,176.34
|
| Rate for Payer: Health EOS Commercial |
$7,422.60
|
| Rate for Payer: HFN Commercial |
$7,672.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,375.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,176.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,176.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,176.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,176.34
|
| Rate for Payer: Multiplan Commercial |
$6,672.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,764.51
|
| Rate for Payer: Preferred Network Access Commercial |
$7,672.80
|
| Rate for Payer: Quartz Beloit One Network |
$4,086.60
|
| Rate for Payer: Quartz Commercial |
$5,421.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,176.34
|
| Rate for Payer: The Alliance Commercial |
$4,705.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,176.34
|
| Rate for Payer: WEA Trust Commercial |
$4,587.00
|
| Rate for Payer: Wellcare Medicare |
$1,176.34
|
| Rate for Payer: WPS Commercial |
$6,177.44
|
|
|
EPICONDYLECTOMY, LATERAL/MEDIAL ELBOW
|
Facility
|
IP
|
$4,912.00
|
|
| Hospital Charge Code |
4494582
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,406.88 |
| Max. Negotiated Rate |
$4,519.04 |
| Rate for Payer: Aetna Commercial |
$4,420.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,224.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,603.36
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,519.04
|
| Rate for Payer: Health EOS Commercial |
$4,371.68
|
| Rate for Payer: HFN Commercial |
$4,519.04
|
| Rate for Payer: Multiplan Commercial |
$3,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,519.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,406.88
|
| Rate for Payer: Quartz Commercial |
$2,947.20
|
| Rate for Payer: WEA Trust Commercial |
$2,701.60
|
| Rate for Payer: WPS Commercial |
$3,638.32
|
|
|
EPICONDYLECTOMY, LATERAL/MEDIAL ELBOW
|
Facility
|
OP
|
$4,912.00
|
|
| Hospital Charge Code |
4494582
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,375.36 |
| Max. Negotiated Rate |
$19,648.00 |
| Rate for Payer: Aetna Commercial |
$4,420.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,224.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,375.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,192.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,456.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,357.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,603.36
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,519.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,748.76
|
| Rate for Payer: Health EOS Commercial |
$4,371.68
|
| Rate for Payer: HFN Commercial |
$4,519.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,684.00
|
| Rate for Payer: Multiplan Commercial |
$3,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,519.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,406.88
|
| Rate for Payer: Quartz Commercial |
$3,192.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,947.20
|
| Rate for Payer: The Alliance Commercial |
$19,648.00
|
| Rate for Payer: WEA Trust Commercial |
$2,701.60
|
| Rate for Payer: WPS Commercial |
$3,638.32
|
|
|
Epidermal Growth Factor Receptor (EGFR) Mutation, Blood
|
Facility
|
OP
|
$1,893.00
|
|
|
Service Code
|
CPT 81235
|
| Hospital Charge Code |
5276620
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$264.01 |
| Max. Negotiated Rate |
$1,741.56 |
| Rate for Payer: Aetna Commercial |
$1,703.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,627.98
|
| Rate for Payer: Aetna Managed Medicare |
$324.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,217.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.80
|
| Rate for Payer: Anthem Medicaid |
$264.01
|
| Rate for Payer: Anthem Medicare Advantage |
$324.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,003.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$324.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$324.58
|
| Rate for Payer: Cash Price |
$567.90
|
| Rate for Payer: Cash Price |
$567.90
|
| Rate for Payer: Cigna Commercial |
$1,741.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$324.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$264.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,059.32
|
| Rate for Payer: Dean Health Medicaid |
$264.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$324.58
|
| Rate for Payer: Health EOS Commercial |
$1,684.77
|
| Rate for Payer: HFN Commercial |
$1,741.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,207.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$324.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$264.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$324.58
|
| Rate for Payer: Managed Health Services Medicaid |
$274.57
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$324.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$324.58
|
| Rate for Payer: Multiplan Commercial |
$1,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$486.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,741.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$264.01
|
| Rate for Payer: Quartz Beloit One Network |
$927.57
|
| Rate for Payer: Quartz Commercial |
$1,230.45
|
| Rate for Payer: Quartz Medicare Advantage |
$324.58
|
| Rate for Payer: The Alliance Commercial |
$1,298.32
|
| Rate for Payer: United Healthcare Medicaid |
$264.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$324.58
|
| Rate for Payer: United Healthcare PPO |
$1,419.75
|
| Rate for Payer: WEA Trust Commercial |
$1,041.15
|
| Rate for Payer: Wellcare Medicare |
$324.58
|
| Rate for Payer: WMAP Medicaid |
$264.01
|
| Rate for Payer: WPS Commercial |
$1,402.15
|
|
|
Epidermal Growth Factor Receptor (EGFR) Mutation, Blood
|
Professional
|
Both
|
$1,893.00
|
|
|
Service Code
|
CPT 81235
|
| Hospital Charge Code |
5276620
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$832.92 |
| Max. Negotiated Rate |
$1,798.35 |
| Rate for Payer: Aetna Commercial |
$1,798.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,627.98
|
| Rate for Payer: Cash Price |
$567.90
|
| Rate for Payer: Cash Price |
$567.90
|
| Rate for Payer: Cigna Commercial |
$1,798.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$946.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,135.80
|
| Rate for Payer: Health EOS Commercial |
$1,722.63
|
| Rate for Payer: HFN Commercial |
$1,798.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,145.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,145.77
|
| Rate for Payer: Multiplan Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,798.35
|
| Rate for Payer: Quartz Beloit One Network |
$832.92
|
| Rate for Payer: Quartz Commercial |
$1,079.01
|
| Rate for Payer: The Alliance Commercial |
$946.50
|
| Rate for Payer: WEA Trust Commercial |
$1,041.15
|
| Rate for Payer: WPS Commercial |
$1,402.15
|
|
|
Epidermal Growth Factor Receptor (EGFR) Mutation, Blood
|
Facility
|
IP
|
$1,893.00
|
|
|
Service Code
|
CPT 81235
|
| Hospital Charge Code |
5276620
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$927.57 |
| Max. Negotiated Rate |
$1,741.56 |
| Rate for Payer: Aetna Commercial |
$1,703.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,627.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,003.29
|
| Rate for Payer: Cash Price |
$567.90
|
| Rate for Payer: Cigna Commercial |
$1,741.56
|
| Rate for Payer: Health EOS Commercial |
$1,684.77
|
| Rate for Payer: HFN Commercial |
$1,741.56
|
| Rate for Payer: Multiplan Commercial |
$1,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,741.56
|
| Rate for Payer: Quartz Beloit One Network |
$927.57
|
| Rate for Payer: Quartz Commercial |
$1,135.80
|
| Rate for Payer: WEA Trust Commercial |
$1,041.15
|
| Rate for Payer: WPS Commercial |
$1,402.15
|
|
|
EPIDRM A-GRFT FACE/NCK/HF/G 15115
|
Professional
|
Both
|
$4,300.00
|
|
|
Service Code
|
CPT 15115
|
| Hospital Charge Code |
3013635
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$138.49 |
| Max. Negotiated Rate |
$4,085.00 |
| Rate for Payer: Aetna Commercial |
$4,085.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,698.00
|
| Rate for Payer: Cash Price |
$1,290.00
|
| Rate for Payer: Cash Price |
$1,290.00
|
| Rate for Payer: Cigna Commercial |
$4,085.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$138.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,580.00
|
| Rate for Payer: Health EOS Commercial |
$3,913.00
|
| Rate for Payer: HFN Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,294.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,294.46
|
| Rate for Payer: Multiplan Commercial |
$3,440.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,085.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,892.00
|
| Rate for Payer: Quartz Commercial |
$2,451.00
|
| Rate for Payer: The Alliance Commercial |
$2,150.00
|
| Rate for Payer: United Healthcare Medicaid |
$138.49
|
| Rate for Payer: WEA Trust Commercial |
$2,365.00
|
| Rate for Payer: WPS Commercial |
$3,185.01
|
|
|
EPIDURAL ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,295.00
|
|
| Hospital Charge Code |
4519580
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$634.55 |
| Max. Negotiated Rate |
$1,191.40 |
| Rate for Payer: Aetna Commercial |
$1,165.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,113.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$686.35
|
| Rate for Payer: Cash Price |
$388.50
|
| Rate for Payer: Cigna Commercial |
$1,191.40
|
| Rate for Payer: Health EOS Commercial |
$1,152.55
|
| Rate for Payer: HFN Commercial |
$1,191.40
|
| Rate for Payer: Multiplan Commercial |
$1,036.00
|
| Rate for Payer: NAPHCARE Commercial |
$777.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,191.40
|
| Rate for Payer: Quartz Beloit One Network |
$634.55
|
| Rate for Payer: Quartz Commercial |
$777.00
|
| Rate for Payer: WEA Trust Commercial |
$712.25
|
| Rate for Payer: WPS Commercial |
$959.21
|
|
|
EPIDURAL ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,295.00
|
|
| Hospital Charge Code |
4519580
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$362.60 |
| Max. Negotiated Rate |
$5,180.00 |
| Rate for Payer: Aetna Commercial |
$1,165.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,113.70
|
| Rate for Payer: Aetna Managed Medicare |
$362.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$841.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$647.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$621.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$686.35
|
| Rate for Payer: Cash Price |
$388.50
|
| Rate for Payer: Cigna Commercial |
$1,191.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$724.68
|
| Rate for Payer: Health EOS Commercial |
$1,152.55
|
| Rate for Payer: HFN Commercial |
$1,191.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$971.25
|
| Rate for Payer: Multiplan Commercial |
$1,036.00
|
| Rate for Payer: NAPHCARE Commercial |
$777.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,191.40
|
| Rate for Payer: Quartz Beloit One Network |
$634.55
|
| Rate for Payer: Quartz Commercial |
$841.75
|
| Rate for Payer: Quartz Medicare Advantage |
$777.00
|
| Rate for Payer: The Alliance Commercial |
$5,180.00
|
| Rate for Payer: WEA Trust Commercial |
$712.25
|
| Rate for Payer: WPS Commercial |
$959.21
|
|
